Marine Safety Investigation Unit

MARINE SAFETY INVESTIGATION REPORT

ANNEXES

Safety investigation into the failure of a lifeboat

wire rope fall resulting in five fatalities and three injuries

on board the Maltese registered passenger ship

THOMSON MAJESTY

while alongside in Santa Cruz de La Palma

on 10 February 2013

201302/008

MARINE SAFETY INVESTIGATION REPORT NO. 05/2014

FINAL / DRAFT / INTERIM

LIST OF ANNEXES

Annex A Wire Rope Certificates of Quality

Annex B Chronology of the Wire Rope

Annex C Report on Wire Rope Load Test

Annex D Report on the Lifeboats and Release Gear Examination

Annex E Classification Society’s Survey Report

Annex F Destructive and Non-Destructive Tests on the Failed Wire Rope

Annex G Chemical Test Report on the Grease Samples

Annex H Davits Manufacturer’s Post-accident Report

Annex I Safety Alert issued by the MSIU

Annex J IMCA’s Wire Rope Purchase Specification

Annex K The North of England P&I Association briefing on Wire Ropes and their

Uses

Annex G

Chemical Test Report on the Grease Samples

Lubetrend is a brand name of ALcontrol UK LTD. Comments are advisory only and data / comments are impaired by non-homogeneous samples and poor sampling techniques. Page 1 of 2

Alcontrol Laboratories

Unit 6

Conwy Morfa Business Park

Conwy

North Wales

LL32 8FA

Oillab@alcontrol.com

Client Name: Stuart Greenfield

Contact details: TMC Marine Consultants Standon House 21 Mansell Street London E1 8AA

Analyst: Christopher Pridmore (MChem, hons)

Date 28/02/2013

Sample No.: 4310684 4310685

System: Grease Grease

Serial No: Mobilarma 798 Rag

Received Date: 25/02/2013 25/02/2013

Objective of Analysis

A piece of towel material impregnated with grease (4310685) was submitted for analysis to determine if the grease on the cloth (Grease 1) is consistent with the supplied reference grease (4310684 – Grease 2).

Testing & Results

Sample 4310685 was refluxed in hot solvents to remove the grease from the material. Extraction yielded a red-brown grease (Grease 1). Grease 1 and Grease 2 (4310684) were both analysed by FTIR and ICP spectroscopy, and their acid number determined, the results of which are shown below.

FTIR trace of Grease 1 (red) and Grease 2 (Blue)

Lubetrend is a brand name of ALcontrol UK LTD. Comments are advisory only and data / comments are impaired by non-homogeneous samples and poor sampling techniques. Page 2 of 2

Alcontrol Laboratories

Unit 6

Conwy Morfa Business Park

Conwy

North Wales

LL32 8FA

Oillab@alcontrol.com

Aluminium

(ppm)

Bariu

m

(ppm)

Boron

(ppm)

Calcium

(ppm)

Chromium

(ppm)

Copper

(ppm)

Iron

(ppm)

Lead

(ppm)

Lithium

(ppm)

Magnesium

(ppm)

Manganese

(ppm)

Molybdenum

(ppm)

Grease 1 19 4 2 127 1 5 896 6 2 105 7 0

Grease 2 0 0 0 9 0 0 0 7 1 0 0 0

Nickel

(ppm)

Phosphorus

(ppm)

Potassium

(ppm)

Silic

on

(ppm)

Silver

(ppm)

Sodium

(ppm)

Sulphur

(ppm)

Tin

(ppm)

Titanium

(ppm)

Vanadium

(ppm)

Zinc

(ppm)

Acid Number

(mg KOH/g)

Grease 1 2 63 11 206 0 98 447 2 12 1 984 9.52

Grease 2 0 0 0 5 0 17 1125 0 0 0 0 0.38

Table 1: ICP spectroscopy data and Acid Number for both greases

Conclusions

The analysis of the extracted grease (Grease 1) has shown it to be consistent with soap based grease showing evidence of substantial oxidation and wear particles. The presence of wear and oxidation is normal in used greases.

The reference grease provided (4310684 - Grease 2) was found to be consistent with a petroleum based material e.g. containing soft paraffin wax, etc.

It is evidence by visual observation the FTIR and ICP comparison of the greases has shown them to be inconsistent. We advise to confirm which product was used in the system.

Annex H

Davits Manufacturer’s Post-accident Report

Doc. 3209 Page 1 of 10

Umoe Schat-Harding Equipment AS N-5470 Rosendal Phone : +47 53 48 36 00 Telefax : +47 53 48 36 01

Document no.:

3209 Document title:

Investigation Report

Thomson Majesty, 02.2013

14.03.2013 Investigation TA AL GAV 17.02.2013 Draft TA

Rev. Date Mark Sign

Contr.

Approved

Doc. 3209 Page 2 of 10

Investigation The below describes the findings of the Umoe Schat-Harding investigation team on the Ship MS Thomson Majesty after a severe incident on 10. February 2013. Vessel : MS Thomson Majesty ex Louis Majesty ex Norwegian Majesty IMO # 8814744 Built: Finland 1992 Registered owner: Majesty Trading Opco LLC Greece Ship manager: Core Marine Ltd Greece Technical manager: Core Marine Ltd Greece Operator: Thomson Cruises UK Flag: Malta Class: NV P&I Club: West of England Ship Owners Investigation team of Schat-Harding: Tormod Abelsen OEM Director Torgeir Langeland Senior Engineer Design Han van Gelder Service Engineer Incident description The incident team reveals that wire fall on life / tender boat station no. 9, broke during the recovery phase of a life boat drill and the boat fell to sea. Investigation subject: Life Boat station no. 9 including the following equipment: Life Boat Davit type MP 246 Winch type W 120 TLD Rigging equipment fall wire Life Boat – NOT investigated Time of investigation: 12 and 13.02.2013. Findings and observations Two vital items related to the incident could not be inspected: The broken part of the fall wire - confiscated by Local Police and Malta Maritime Authority The floating / lowering block – missing Davit observation The general impression of the davit at first sight seems acceptable but going into the details revealed major negative conditions:

Doc. 3209 Page 3 of 10

Severe corrosion in some of the bearing and bolt penetration areas. Some just covered by paint.

Stuck bearings and bolts in the pivot points

Lack of greasing in pivot points

Doc. 3209 Page 4 of 10

The position of limit Switches in way of stop function seems random – uncertain if the davit arm is stopped before reaching end position

The mirror davit to the investigated that is position 10 seems not to have been in operation for some time - this had no indication of greasing and was painted “ together “. Fall Wire observation The condition of the fall wire can only be determined by inspection of the stressed and exposed areas . This revealed the following –

Clearly corroded in sheave areas

Doc. 3209 Page 5 of 10

In spot areas corroded strands to decomposition.

Clear signs of “open“ wire in sheave areas on davits with tight wire – exposed to water and salt Entrance (The photo is unfortunately not giving a perfect view of the real situation.) Three of the Life / tender boat stations had 24 mm wire as specified but not the correct wire configuration

The wire at the damaged station ( no. 9 ) was measured to be 22.7 mm – incorrect dimension but correct wire configuration The Life / tender Boat station no. 9 / 10 being mirror station had as stated different wire type –

Station no. 9: Right lay – Regular lay

Doc. 3209 Page 6 of 10

Station no. 10 Right lay – Lang lay The dimension measured at Life boat station no. 9 – 22.7 mm is identical to the Life boat station no. 11 and 12. Winch observation The observation of the winch clearly revealed that modifications without consent of OEM had been performed to the object –

The winch at station no. 9 is welded to the foundation

Big gaps is seen between the original foundation and the winch frame

Doc. 3209 Page 7 of 10

Some welding have been done on the bearing shaft at the end of the drum

Bending of the flange to the drum of the remote control wire was observed

The hydraulic pipe connection between the pump and oil tank is welded - normally and originally this should have an elastic coupling

Doc. 3209 Page 8 of 10

Pipe for brake release system is replaced with non original parts – copper pipe material, the pipe was not clamped as specified Remote control wire is not installed Additional observations and comments As stated the breaking spot or area of the fall wire was not inspected. Information from the investigation team of Malta Maritime Authority stated the half of the wire had been confiscated by named and would be sent to laboratory for investigation and testing. The floating / lowering block was missing. Only after having been stated by USH Investigation team that it could be of vital importance to find this it seems like initiative would be taken – whether this was followed up or not is unknown to us.

The damaged Tender boat including the boat hooks was not accessible for inspection – only observed from a distance. The incident was filmed by one of the ships surveying cameras and showed to USH investigation team observing the following sequence of happenings – The Life / tender boat is hoisted and pulled in approximately 0,5 meter

Doc. 3209 Page 9 of 10

The hoisting is stopped and bowsing gear is connected to the floating / lowering block. The video that we saw is starting from this point. Lowering of the Davit / Boat to the outer most position. The boat is paneling for a short time and re hoisting is started. After approximately 1 meter turning in of the davit arm the forward part of the boat is falling down. Just before the lifeboat came into vertical position the boat ‘disconnected’ from the aft lowering block and the boat drops to the sea. Forward davit arm fell out with a visible ruff stopping at outermost position. The video did not show the floating / lowering block or davit head. The method of recovery of the boat is not according to the User and maintenance instruction ( page 11 ). The Life / Tender boat was recovered with more people than specified in the manual – ( 8 no. persons / manual 4 no. persons ). The actual weight of the Life / tender boat is at present unknown. It is also noted that the other lifeboat/tender stations was stowed with tightened wires. This is not according to User and maintenance instruction (page 11, item 9) Upper part of the main davit arm is found damaged (deformed) after mentioned incident.

Actions taken by the Investigation team onboard the Ship Addressed Captain George Koumpenas. Date: 13.02.2013 Recommendation was given not to use the davit and winch until proper detailed examination, repair or replacement have been undertaken. Documentation and findings The wire: In addition to described and documented observations the findings are: Wire specification ( as given in GA drawing ): Ø24mm CASAR EUROLIFT 1770 N/mm 2 MBL= 474 kN Wire specification ( as given in Manual ): Ø24mm PYTON 505 MBL= 474 kN Wire installed ( as informed us by Malta Safety Investigation Unit (MSIU )): Ø24 36 x7 + SE 1670 N/mm 2 MBL=306.3 kN The installed wire has a MBL of 65 % to the required The wire breaking point: The location of the wire breaking point have been calculated and determined: Ref. Document no. 3226.

Doc. 3209 Page 10 of 10

Conclusive explanation The direct explanation to the incident is mainly the use of wrong type of wire with a too low SWL/MBL which also had severe corrosion in addition to other negative contributions as: The incorrect wire installed having a Breaking Capacity of only 65 % of the Required ( ref. wire certificate ). The severe corrosion and lack of greasing, probably stuck bearings in pivot points increasing the friction and thus the recovery load on the davit. Recovery performed not in accordance to the Operational Manual inducing additional load to the wire. The outcome of inspection and laboratory tests of braking point of wire have not yet been revealed ( according agreement MSIU will inform us ). Documentation More pictures and some documents can be found on AS server - T:/Standard-documents/Working files 3000-3500/3209/ P:/010_ .... Business risk evaluation Document no. 3226 Evaluation 1 ( Location of wire breaking point ) Other incident documentation L:/Beredskapssaker/Thomsen Majesty/..

Annex I

Safety Alert issued by the MSIU

Annex J

IMCA’s Wire Rope Purchase Specification1

1 This Annex was reproduced by permission of the International Marine Contractors Association

(IMCA).

Example Wire Rope Purchase Specification

IMCA SEL 022, IMCA M 194 43

Appendix 2

Storage requirements – the following information should be provided by the supplier to the purchaser:

Note: Manufacturer must verify that ABF is greater than required MBF.

Illustrative example of an existing certificate for guidance only (companies’ requirements will vary)

Delivery – the following are required by the purchaser

� Wire rope

� Transport reel

� Certificate

� 10 metallic ID tags

Intended use:

Crane main lifting wire Tugger winch wire

Crane auxiliary wire Guide wire

Crane luffing wire

Other

Technical requirements:

Rope category class (ISO 4309:2004 Annex E) RCN =

Rope construction

Galvanised Yes

Rope core IWRC FC WSC

Direction of lay Left Right

Type of lay

zS sZ

sS zZ

S Z

Nominal diameter (d) mm

Rope length (L) m

Minimum breaking force (MBF) (design) kN

Production standard ISO 2408 EN 12385

Diameter tolerance 0% 5%

L <400m

Length tolerance L >400m

L >1000m

0% 5%

0m 20m

0% 2%

Lebus drawings should be attached by the purchaser to this specification

Transport reel and terminations:

SWL 3% MBL

Socket type:

Tension on transport reel 1% MBL

Total weight (wire rope and reel)

The rope shall be delivered on a transport with metallic tags for identification, with one tag each end. The outer end shall be seized and have

a small pull eye welded to the wire end. The inner end shall be equiped with an open spelter socket. The following specifications should

be met:

Spooling on to the final drum shall be the responsibility of: Supplier Purchaser

Spooling tension: 2% MBL

Spooling on to final equipment

Certificate – the following content must be included on the certificate to be provided by the supplier to the purchaser:

� Certificate number

� Name and address of manufacturer

� Name and address of supplier

� Intended use of rope

� Nominal diameter

� Minimum breaking force (MBF)

� Length of delivered wire rope

� Ref. to production standard

� Rope type, RCN class, construction

� Actual breaking force (ABF) (less than 3 months before delivery)

� Manufacturer’s instructions for storage conditions

� Manufacturer’s instruction for rotation of reel

� Manufacturer’s instructions for examination and application of

dressing

Annex K

The North of England P&I Association briefing on Wire Ropes and their Uses